Pasadena Grove Health Center

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's rights regarding formulating an Advanced Health Care Directive (AHCD- is a legal document that outlines a person's medical care preferences and name a trusted person to make medical decisions if the patient becomes incapacitated [being completely unable to manage one's affairs or makes decisions due to a physical or mental limitation]) were honored for one of two sampled residents (Resident 1) by failing to verify the resident's capacity to make decision, the facility did not involve the legally recognized decision-maker and did not ensure proper witnessing for an AHCD executed inside a skilled nursing facility. These failures resulted in an invalid AHCD and jeopardized the resident's right to have healthcare decisions made according to their expressed preferences.

Inspectors wroteBased on interview and record review the facility failed to promote dignity and respect for one (1) of nine (9) sampled residents (Resident 1) when Certified Nursing Assistant 1 (CNA 1) stated he had repeated a derogatory word (saying or doing something that is insulting, disrespectful, or meant to belittle someone) in Resident 1's language to the resident and had tossed a pillowcase onto resident's face while playing with Resident 1 on 6/8/2026. This failure had the potential to affect Resident 1 experiencing psychosocial effects (a person's mental, emotional, social and spiritual health) and had the potential to affect the resident's self-esteem, self-worth and violated Resident 1's right to be treated with dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of two residents (Resident 1) from abuse (the willful infliction or injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) when Resident 2 allegedly threw a blanket over Resident's 1's head and hit Resident 1 with a metal object on 5/28/2026. This deficient practice resulted in Resident 1 having an abrasion (injury where top layer of skin is scraped or rubbed away due to friction against a rough surface) on the left cheek and a cut on the left upper lip with the potential for emotional and psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) for one (1) of six (6) sampled residents (Resident 1). This failure resulted in the loss of Resident 1's cell phone and laptop, the transfer of funds from Resident 1's bank account to Certified Nurse Assistant 2's (CNA 2) bank account and a credit card account being opened and mailed to CNA 2's address. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 2) was free from unnecessary psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) as indicated in the facility's policy and procedure by failing to ensure Resident 2 had a specific indication for the use of Buspirone Hydrochloride (HCL) (a prescription medication used to treat symptoms of generalized anxiety disorder[emotion characterized by feelings of tension, worried thoughts and physical changes]). [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of two sample residents (Resident 1) by failing to follow up with the physician when the physician discontinued Atorvastatin (Lipitor, a statin [a class of drugs] medication used to lower cholesterol and reduce the risk of heart disease, heart attack and stroke) due to a possible cross allergic risk (the potential for an allergic reaction to occur when the immune system recognizes proteins in one substance as similar to proteins in another). This deficient practice had the potential to result in Resident 1 having unintended problems related to cholesterol management which could lead to further cardiovascular complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a medication as indicated on the physician's order for one of two sampled residents (Resident 1) by failing to administer Symbicort Inhalation Aerosol 160-4.5 microgram/actuation (mcg/act, indicates the amount of medication delivered in a single puff from an inhaler) to Resident 1 from 4/4/2026 to 4/23/2026 (did not admit medication for 20 days and total 39 doses missed). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment that is free from accident hazards for two (2) of three (3) sample residents (Residents 44, and 9) reviewed for accident hazards by failing to ensure:A black synthetic gait belt (a type of belt used to support, steady, or assist a resident during movement), approximately five (5) feet long, was not left on the floor near Resident 44's bed. Resident 9's feet were not dangling while sitting in the wheelchair. The base of the Hoyer lift (a mechanical device designed to safely transfer individuals with limited mobility between surfaces, such as a bed, chair, or wheelchair) stored in the hallway was not left wide open. The lint trap was cleaned on 4/3/2026 at 8AM, 10AM, and 12PM from the facility's two of two dryer's machines (Dryer 1 and 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the food service area in a clean and sanitary condition and failed to follow its proper food - handling policy procedure by failing to ensure: A container of lentils was properly covered with a lid. The can opener was sanitized and free of dry food residue. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home-like environment for two (2) of five (5) sampled residents (Resident 11 and 18) reviewed for environment by failing to:Ensure Resident 11's bedside rails (safety devices or barriers attached to the sides of a bed to prevent falls, assist with repositioning, and provide support for getting in and out of bed) foam padding was in good condition. The facility failed to ensure two wash basins and three hand towels were not placed in the toilet tank in Resident 18 's restroom. These deficient practices caused an unsanitary and had potential for residents to be placed at risk for serious illness and/ or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a communication device in hospitals and nursing homes that allows patients to alert staff for assistance) was within arm's reach for one (1) of four (4) sampled residents (Resident 7) reviewed for environment in accordance with the facility's policy and procedure (P&P) titled, Communication - Call System: This deficient practice had the potential for Resident 7 not to be able to call the facility staff for help or assistance, especially during an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to secure the residents personal and medical records when the facility did not destroy identifiable information on the resident's discarded oxygen humidifier (bottle device attached to an oxygen concentrator [a medical device that provides supplemental oxygen to people with breathing disorders], tank, or liquid system to add moisture to dry medical oxygen, reducing nasal dryness, nosebleeds, and throat irritation) container for one (1) of 17 sampled residents (Resident 6). This deficient practice has the potential for unauthorized release of resident's personal information.

Inspectors wroteBased on interviews, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that every resident entering a Medicaid Certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II Evaluation to ensure that the NF residence is appropriate and to identify what specialized services the resident may need) for one (1) of three (3) sampled residents (Resident 10) reviewed for PASRR care area, in accordance with the facility's policy. This deficient practice had the potential to result in inappropriate placement of Resident 10 and had the potential for the resident not to receive the necessary care and services the resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LAL mattress, a specialized medical bed mattress designed to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] by constantly blowing a tiny amount of air through small holes in its surface) was at a correct setting for one (1) of two (2) residents (Resident 21) reviewed for pressure ulcer , in accordance with the facility's policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the oxygen via nasal cannula (NC, a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) was administered for one (1) of three (3) sampled residents (Resident 66) reviewed for respiratory services in accordance with the facility's policy. This deficient practice had the potential for Resident 66 not being able to receive the benefits of the supplemental oxygen ordered and had the potential to compromise the resident's respiratory function which could lead to complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) dumpsters (a movable waste container) were closed and not overflowing, in accordance with the facility's Garbage and Trashcan Use and Cleaning Policy and Procedure (P&P). This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species), increasing the risk of disease transmission and health issues for residents, staff, and the surrounding community.

Inspectors wroteBased on interviews and record review, the facility failed to maintain a complete and accurate medical records for three (3) of 17 sampled residents (Residents 12, 21, and 9) in accordance with the facility's Charting and Documentation policy and procedure (P&P) by failing to ensure: 1. Resident 21's sacro-coccyx (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and the tailbone) wound care treatment in the Treatment Administration Record (TAR) on 3/15/26, 3/16/2026 and 3/17/2026.2. Resident 9's physician order for Seroquel (drug used to treat schizophrenia) included an indication for use.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within resident's arm's reach for one (1) of five (5) sampled residents (Resident 21) reviewed for environment in accordance with the facility's policy. This deficient practice had the potential for Resident 21 not to be able to call the facility staff for help or assistance, especially during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Daily Staffing Report (Nurse Staffing Information) posted on 3/31/2026 and 4/2/2026 was accurate by failing to reflect the correct total number and actual hours of licensed nursing staff directly responsible for resident care, in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to misinform residents, families, and the public regarding the actual nursing staff providing direct care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate documentation for the resident's Physician Discharge Summary and behavior monitoring for one (1) of two (2) sampled residents (Resident 1). This deficient practice had the potential to affect the accuracy of clinical assessments and medical management for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) for abuse for two (2) of two sampled residents when the facility failed to investigate an allegation of abuse by Resident 2 to Resident 1 on 12/18/2025. On 12/18/2025, Resident 1 reported to Registered Nurse 1 (RNS 1) that Resident 1 was getting harassed (to experience persistent, unwelcome conduct that is offensive, intimidating, or humiliating, often targeting a person's protected traits like race, gender, or religion, or simply making them feel threatened, distressed, or that creates a hostile environment) and assaulted (threatening or attempting to physically harm someone, causing them to reasonably fear immediate injury, even without actual contact) by Resident 2. [...]

Inspectors wroteBased on interview and record review the facility failed to report an alleged abuse (willful infliction of injury resulting to physical harm/pain or mental anguish) to the State Survey Agency (California Department of Public Health-CDPH- where state law provides for jurisdiction in long-term care facilities), Ombudsman (OMB- advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (PD) within two (2) hours after the allegation of abuse was reported to Registered Nurse Supervisor 1 (RNS 1) for two of two sampled residents (Resident 1 and 2) This deficient practice had the potential to place Resident 1 and 2 at risk for further abuse and/or under reporting from the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately inform the physician of one of two sampled residents (Resident 1), who had a diagnosis of hypertension (high blood pressure) and cerebral infarct (the death of brain tissue from a sudden blockage of blood flow, depriving brain cells of oxygen and nutrients) of Resident 1's change of condition by failing to: 1. Ensure the physician was notified by licensed nurse when Resident 1 was reported by Certified Nurse Assistant (CNA) 1 that Resident 1 was sleepier than usual on 12/7/2025 and 12/8/2025.2. Ensure Licensed Vocational Nurse 1 (LVN 1) notified Resident 1's physician timely within 15 minutes from when Resident 1 had a change of condition when Resident 1 was assessed to have a blood pressure (BP) of 153/91 millimeters of mercury (mmHg - a standard unit of measuring blood pressure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered to meet the needs of each resident and in accordance with professional standards of practice for one of two sampled residents (Resident 1) and 3 of 4 medications (anticonvulsant, antipsychotic, and insulin). Resident 1 had three consecutive episodes of noncompliance behavior (refused medications, on 8/2, 8/3, 8/4/2025 [anticonvulsant], on 8/9, 8/10, 8/11/2025 [antipsychotic], and on 8/2, 8/3, 8/4/2025 [insulin]) for three different medications and the doctor was not notified, per the care plan interventions. In addition, Resident 1's blood glucose was not obtained prior to administration of insulin, in accordance with the policy and procedure titled, Medication - Administration, revised 11/1/2017. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged incident of staff to resident abuse for one (1) of four (4) sampled residents (Resident 1) within 2 hours to the state survey agency, adult protective services, law enforcement and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) according to federal and state regulations and facility policy. This deficiency resulted in the delay of onsite inspections and investigations which led to potential for Resident 1 to experience ongoing abuse from facility staff and/or other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity and maintain privacy for one of two sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's self-worth and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure to ensure an allegation of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was reported to California Department of Public Health (CDPH), local law enforcement, and Ombudsman within two (2) hours for two of two residents (Residents 1 and 2). This deficient practice had the potential to place Resident 1 and other residents in the facility at risk for further abuse and resulted in a delay in the investigation for the abuse allegation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for three (3) of 3 sampled residents (Resident 27, 28, 38) who was dependent with activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), by failing to ensure the residents' nail were kept trimmed and clean in accordance with the facility's policy. This deficient practice resulted in Resident 27, 28, and 38 having dirty, long and jagged (having rough, sharp points protruding) fingernails, potentially leading to skin injury, infection, and scarring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure by failing to label and discard expired food items stored in the facility's kitchen refrigerators, freezers, and dry storage. This deficient practice had the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 50 residents consuming food by mouth.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy on Covid-19 (Coronavirus Disease 19, a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) by failing to: 1. Provide education, offer, and document the 2024-2025 Covid-19 vaccinations for two of five sampled residents (Residents 2 and 17). 2. Provide education, offer, and/or document the 2024-2025 Covid-19 vaccination for staff. This deficient practice place residents and staff at risk for possible Covid-19 infection due to missed vaccination dosage.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident received reasonable accommodation of needs for two (2) of 18 sampled residents (Residents 17 and 28) by failing to ensure Residents 17 and 28's call lights were within reach. This deficient practice had the potential to result in the inability for Residents 17 and 28 to obtain necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the preadmission screening and resident review assessment (PASRR, preventing individuals with mental illness, developmental disability, intellectual disability, or related conditions from being inappropriately placed in nursing homes for long term care) form was accurately completed for a resident who had a mental illness for one (1) of three (3) sampled residents (Resident 2). This deficient practice had the potential for Resident 2 to not receive the necessary and appropriate psychiatric (of or relating to the study of mental illness) treatment and evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the fall care plan for one (1) of 18 sampled residents (Resident 2) in accordance with the facility policy. This failure had the potential to place Resident 2 at risk for further falls, which could result in harm/injury to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for one of three sampled residents (Resident 36). This deficient practice placed Resident 36 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 16) receiving 5 liters of oxygen therapy (the odorless gas that is present in the air and necessary to maintain life) had a physician's order. This deficient practice had the potential to result in negative outcome of Resident 16's breathing pattern.

Inspectors wroteBased on interview and record review, the facility failed to provide one of one sampled resident (Resident 30) safe and appropriate care for the provision of dialysis (a lifesaving treatment for residents with kidney failure) consistent with professional standards and in accordance with the facility's policy by failing to: 1. Ensure Resident 30 received 1800 milliliters (ml, unit of volume) of fluids per day as indicated on the care plan. 2. Monitor Resident 30's fistula (an abnormal opening or passage between two body structures that do not normally connect) for dialysis access. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication was administered per physician's order for one of four sampled residents (Resident 21). This deficient practice had the potential for delayed absorption and decrease effectiveness of the medication, which could affect Resident 21's wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to act upon the facility's Pharmacy Consultant's recommendations during the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to address the recommendation/ irregularities for the month of January 2025's MRR for one (1) of five (5) sampled residents (Resident 4). This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lids of one garbage container (dumpster) remained closed as indicated in the facility policy titled, Garbage and Trash Can Use and Cleaning. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, such as rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure provision of hospice (specialized care providing physical comfort and emotional, social and spiritual support for people nearing the end of life) services for one of two sampled residents (Resident 36) by failing to ensure: 1. Hospice nurses (Skilled Nurses [licensed nurses] and Certified Home Health Aide [CHHA]) conducted a visit according to the hospice care summary order. 2. Hospice calendar for 2/2025 was completed to reflect frequency of hospice SN and CHHA visits according to the care summary order. These deficient practices had the potential to result in a delay or a lack of necessary care and services which could negatively affect Resident 36s' physical comfort, psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship to reduce inappropriate antibiotic (medication used to kill bacteria and to treat infections) use by not administering antibiotic drug if the antibiotic drug use criteria (Loeb's, an Infection Screening Evaluation in facility's medical record, surveillance definitions of infections in Long-Term Care Facilities) was not met for one (1) of two (1) sampled residents (Resident 206). [...]

Inspectors wroteBased on interview and record review, the facility failed to administer pneumococcal vaccination (vaccine that protect against bacteria that cause illnesses such as pneumonia [infection of the lungs], ear infections, sinus infections, meningitis [infection of the tissue covering the brain and spinal cord], and bacteremia [infection of the blood]) for one of five sampled residents (Resident 30) after obtaining a consent on 2/7/2025. This deficient practice placed Residents 30 at higher risk of acquiring and transmitting complications from the pneumococcal disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the accurate and complete Census and Direct Care Service Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) in accordance with the facility's policy and procedure by failing to ensure the Postage Nursing Hours for Direct Care Staff (nurse staffing information) posted on 2/25/2025 was accurate to reflect the correct date and total number of projected hours and the actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice had the potential for residents and visitors not to be informed of the facility census and staffing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 31 of 31 Resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 and 32) met the 80 square feet (sq. ft.) per Resident in multiple resident rooms. This deficient practice had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to monitor the intake and output for two (2) of 2 sampled residents (Resident 1 and 3) who had an indwelling catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) according to facility's policy. This deficient practice had the potential to delay in the necessary care and services for Resident 1 and 3 which can lead to serious illness or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management to two (2) of 2 sampled residents (Resident 1 and 2) as indicated on the physician's order and facility policy by failing to: 1. Administer Acetaminophen (a medication used to treat minor aches, pains, and to reduce fevers) to Resident 1 as indicated in the physician's order and notify physician of increased onset of pain. Resident 1 received Acetaminophen 325 milligrams (mg, unit of measurement) 2 tablets which was indicated for mild pain (1-3/10) when Resident 1 complained of pain level of 7/10 on 10/29/2024. 2. Administer Acetaminophen to Resident 2 as indicated in the physician's order. Resident 2 received Acetaminophen 500 mg which was indicated for mild pain (1-3/10) when Resident 2 complained of pain level of 4/10 on 8/24/2024 and 9/29/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to honor the rights for one of two sampled residents (Resident 1) as indicated in the facility policy by failing to honor Resident 1's request to keep his personal cellphone at bedside. This failure resulted in a violation of Resident 1's rights and had the potential to negatively impact his emotional and/ or mental well-being (the state of being comfortable, healthy, and/or happy).

Inspectors wroteBased on interview and record review, the facility failed to obtain urine sample for urine analysis as indicated in the physician's order for one of two sampled residents (Resident 1). This deficient practice had the potential to delay necessary care and services, not optimized for the best possible health outcomes and the potential to cause a negative impact on the resident's overall physical well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of five sampled residents (Resident 1) was provided a communication board (a device displaying photos, symbols, or illustrations to help residents with limited language skills express themselves) that was readily accessible with the language Resident 1 was able to understand. This failure had the potential to result in Resident 1 experiencing a delay in receiving appropriate care and treatment, which could result in harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for one (1) of four (4) sampled residents (Residents 1) to address inappropriate behavior and wandering as indicated on the facility policy. This failure had the potential for Resident 1 not to receive interventions specific to the resident's needs, which could result in injury and harm to Resident 1 and other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision in accordance with the facility policy for one (1) of four (4) sampled residents (Resident 1) who was reported to exhibit inappropriate behavior and was observed with episodes of wandering. This deficient practice resulted to Resident 1 wandering into another resident's room with an allegation from the other resident (Resident 2) of inappropriate touching. This deficient practice also had the potential for Resident 1 to sustain injury and harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach and failed to provide an adaptive call light (specialty call light that will fit the resident's need if unable to use the regular call light with a call button) for one (1) of four (4) sampled residents (Resident 2) as indicated in the facility's policy and procedure and care plan. This deficient practice had the potential not to meet Resident 2's needs and preference.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for two of two sampled residents (Residents 1 and 4) by failing to ensure Residents 1 and 4's call lights (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) were within the resident's reach and the call lights were answered promptly as indicated in the facility's policy and procedure. This deficient practice had the potential for Residents 1 and 4 not to receive emergency and/ or necessary care or have a delay in care and services that could result in an accident such as fall and/ or skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care for three of three sampled residents (Residents 1, 4, and 6) in accordance with professional standards of practice and the facility's policy and procedure by: 1. Failed to assess, document, and notify Resident 1's Attending Physician regarding the resident's pacemaker's (an artificial device for stimulating the heart muscle and regulating its contractions) dressing status. 2. Failed to check Resident 4 and 6 every two hours if they needed diaper change and/ or as needed when residents called to request for diaper change. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pain management (the process of alleviating pain) for one of two sampled residents (Resident 2) by not implementing the facility policy and procedure on pain management. This deficient practice had the potential to result in Resident 2 to experience unrelieved pain.

Inspectors wroteBased on interview and record review, the facility failed to administer prescribed medications to two of three sampled residents (Resident 2 and Resident 3) as ordered by the doctor. These failures resulted in Resident 2 and Resident 3 not receiving their prescribed medication as ordered according to their plan of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled facility staff (Certified Nursing Assistant 1 - CNA 1) had the competency necessary to care and ensure resident safety as identified through resident assessments, plan of care, and facility policy. This deficient practice had the potential in resident falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1 and 2. Monitoring of placement and function of the WanderGuard (a monitoring device [bracelet] that alarms when a resident tries to exit out of the door) for two of two residents (Resident 1 and 2) as indicated in the physician's order and care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs). 3. There was a system in place to test the WanderGuard bracelet for functionality as indicated in the WanderGuard manual. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its own abuse policy and procedure (P&P) by failing to investigate and report allegation of abuse and submit the follow up investigation report in a timely manner for two of two sampled residents (Resident 1 and Resident 2). These deficient practices put the facility's residents at risk for potential abuse by failing to identify and report abuse in timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of three (3) sampled residents (Residents 1 and 2) who were assessed as high risk for elopement (to go about from place to place usually without a plan or purpose that leads a resident to completely leave the facility, unsupervised and unnoticed) were provided supervision when the courtyard gate alarm (a small device mounted next to the door to monitor the movement of the door) was broken. This failure resulted in Resident 1 and 2 having a successful elopement which had the potential to lead to injury while outside the facility's premises without supervision from staff. Resident 2 was found on 3/11/2024 and Resident 1 remained missing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for two of three sampled residents (Resident 35 and 1) for dignity care area. The facility staff was observed standing above Resident 35 and Resident 1's eye level while assisting the residents during dinner. This deficient practice had the potential to affect Resident 35 and Resident 1's self-esteem and self-worth and violate Resident 35 and 1's right to be treated with dignity.

Inspectors wroteBased on interview and record review, the facility failed to follow their Advance Directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapable) for three (3) of 3 sampled residents (Resident 30, 29, and 116) when facility failed to ensure: 1. Resident 30's Advance Directive was maintained in the resident's chart. 2. Resident 116 had a documented evidence on being informed of his choice to complete an Advanced Directive. 3. Resident 29 had a documented evidence on being informed of his choice to complete an Advanced Directive. This deficient practice had the potential not to carry out Residents 30, 116, and 29's wishes regarding health care decisions during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) for three (3) of 3 sampled residents (Residents 30, 3, and 45) for pressure injury care area, in accordance with the facility's policy and procedure by failing to ensure: 1. Resident 30's low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct setting. 2. Resident 3's LAL was on the correct setting. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory services for two (2) of 2 sampled residents (Residents 34 and 35) for respiratory care area, in accordance with the facility policy. 1. The facility failed to ensure Licensed Vocational Nurse (LVN 1) did not leave Resident 34 unattended during the administration of her scheduled dose of Budesonide (medication that makes breathing easier by reducing the irritation and swelling of the airways) via a handheld nebulizer (a machine that delivers medicines in the form of aerosols to add moisture and help control the respiratory symptoms). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in a sanitary manner to prevent the growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) as indicated on the facility policy by failing to ensure: 1. Personal items of kitchen staff were stored in the designated area. 2. Personal food of the kitchen staff was not left on top of the food preparation table and was not placed in the kitchen refrigerator. 3. Utensils drawer and utensils were free from dirt and debris. 4. Food items in the facility's kitchen, two (2) freezers located in the dietary office and dry storage were labeled and dated with the received and opened date. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for three (3) of four (4) sampled residents (Residents 13, 214, and 266), for infection control care area, by failing to maintain infection control measures when: 1. Resident 13 who was on contact isolation (used for infections, diseases, or germs that are spread by touching the resident or items in the resident room, healthcare workers are required to wear gloves, gown and optional mask during care) for Carbapenem-Resistant Enterobacterales (CRE, a type of bacteria that can cause severe infections and are resistant to most available antibiotics including strong antibiotics called carbapenems) was allowed to participate in activities held in the Activity Room with other residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent for two (2) of 17 sampled residents (Resident 15 and 115): 1. Resident 15 did not have a psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) consent form for the use of trazodone (medication used to treat depression and anxiety disorders) and Zyprexa (medication used to treat certain mental/mood disorders). 2. Resident 115 was not provided a consent form for the use of wander guard (a wearable bracelet integrated with a resident's security system to alert care givers when the resident has wandered from the protected zone). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the residents' needs for five (5) of 17 sampled residents (Residents 34, 13, 15, 29 and 35) as indicated on the facility policy: 1. and 2. Residents 34 and 13 did not have an individualized resident-centered care plan addressing Restorative Nursing Assistant (RNA) services for range of motion exercises (ROM, extent of movement of a joint). This deficient practice had the potential to result in a lack or delay in the delivery of necessary care and services, which could result in Residents 34 and Resident 13 developing contractures (abnormal shortening of muscle tissue). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an environment that was safe and free from accident hazards, in accordance with the facility's policy for one (1) of three (3) sampled residents (Resident 15), for accidents care area, when Resident 15 was found in possession of an illegal substance on 2/1/24. This deficient practice had the potential for other residents to have access to the illegal substance and place Resident 15 and other residents at risk for harm and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional services for one of one sampled resident (Resident 45 ) for nutritional care area when: 1. Resident 45 was not provided assistance as assessed on the Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) during lunch on 2/22/24 and was not on the Restorative Nurse's Aide (RNA) feeding program (a program that provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible by focusing on achieving and maintaining optimal physical, mental, and psychosocial functioning) as indicated on the physician's order and care plan. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within the resident's reach (arm's length) for one (1) out of 17 sampled residents (Resident 30) as indicated on the facility's communication-call light policy. This deficient practice had the potential for Resident 30 not being able to call the facility's staff for help or assistance especially during an emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure facility remains free of pests (a general term for organisms [rats, insects, cockroach etc.] which may cause illness) and rodents (a type of small mammal with sharp front teeth such as rats, mice, and squirrels) for one (1) of four (4) sampled residents (Residents 9) in accordance with the facility's policy and procedure. This deficient practice had the potential for Resident 9 and other residents to be bitten by cockroaches, which could result to irritation, lesions, swelling, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 31 of 31 Resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 and 32) met the 80 square feet (sq. ft.) per Resident in multiple resident rooms. This deficient practice had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to permit one of one sampled resident (Resident 1) to be admitted to the facility on ce they have an open bed available on 12/14/2023. As a result, Resident 1 remained in the general acute care hospital (GACH) from 12/14/2023 to 12/17/2023 (a total of four [4] days) waiting to be admitted to the skilled nursing facility (SNF 1). Patient 1 was subsequently discharged by the GACH to another skilled nursing facility (SNF 2) on 12/18/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were implemented as indicated on the Centers for Disease Control and Prevention (national public health agency) guidelines by: 1. Failing to label contaminated laundry. 2. Failing to have a trash can for doffing(remove an item of clothing) of personal protective equipment (PPE, protective clothing designed to protect the wearer's body from infection) at doorway for PPE doffing. This deficient practice had the potential for spread of Coronavirus 2019 (COVID-19, infectious disease caused by coronavirus) to the residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive and resident-centered care plan to prevent falls (unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an external force) for one of four sampled residents (Resident 3). Resident 3's care plan did not indicate how often Resident 3 should be observed or monitored to prevent from falling. This deficient practice resulted in Resident 3 suffering an unwitnessed fall which resulted in an acute right femoral neck fracture (right hip fracture).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 3) who was assessed at high risk for falls (unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an external force) with severely impaired vision. This deficient practice resulted in Resident 3 suffering a fall which resulted in an acute right femoral neck fracture (right hip fracture).